Harnessing non-state actors for better health for the poor: Dispelling the myths about informal providers

posted Nov 8, 2012, 3:50 AM by Kate Hawkins [ updated Nov 8, 2012, 9:07 AM ]

by Tom Feeny (Programme Manager, HANSHEP)

Informal providers, like ‘the poor’, have historically proven to be a largely elusive population within health and development. Confounding neat categorisation within the already blurry boundaries of the ‘private sector’, informal providers are typically the subject of sweeping generalisations whose credibility rests precariously on very basic perceptions of these individuals being simply ‘outside the institutional framework’ and therefore ‘unregulated’, ‘disorganised’ and ‘uneducated’. With donors and governments historically directing their attention primarily to stakeholders within the public system and to civil society groups, informal providers have quietly proliferated in the background – to the point that they now represent a vital source of care (and importantly, the first point of contact) for many in middle and low-income countries, especially the poor. Perhaps most significantly, they have succeeded in reaching the hard-to-reach where so many before them have failed, and are have embedded themselves within the local community fabric to the extent that their inclusion in health strategies at any level is surely now without question.

However, harnessing these informal providers effectively requires us to first understand them, and through research create a more nuanced contextual picture of their contribution in order to dispel the often unhelpful myths that have arisen and still persist.

Recognising this, the Centre for Health Market Innovations (which is supported by HANSHEP members) launched a research project with partners in Bangladesh, India and Nigeria to explore the characteristics of some of these informal providers, and the dynamics of their interaction with the broader health system. Focusing on Village Doctors (VDs) in Bangladesh, Rural Medical Practitioners (RMPs) in Utarrakhand and Andhra Pradesh states in India, and Patent Medicine Vendors (PMVs) in Nigeria, the researchers today presented some striking findings from these studies at the Second Global Symposium on Health Systems Research in Beijing. While the three case studies did not align on every indicator, they still revealed the following important insights:

Informal providers are highly respected members of their communities, often attracting far greater trust than formal providers due to their having been locally established for many years (an average of 10-15 years for RMBs in India and sometimes up to 30 years serving the same community).
They often have higher levels of education than the national average. In Bangladesh, 67% of VDs had completed secondary education (compared to 13% at the national level), are well connected to the local social elite and through their frequent patient visits/follow-up sessions are also often asked to advise on many issues beyond those related to health.
The majority have completed some form of training (e.g. Pharmacist or Community Health Worker courses provided by NGOs or through apprenticeships with registered doctors), although the quality, content and qualifications resulting from these sessions remains unclear.
Like their public counterparts, they are relatively knowledgeable about certain case standards and undertake appropriate practice in some areas. In India, RMP knowledge levels were fairly high (70%) when compared to WHO guidelines, although they, like the VDs in Bangladesh, exhibited harmful and wasteful practices, including very high levels of polypharmacy (prescribing several medicines for one illness).
They often have strong relationships with stakeholders in the formal sector, with VDs hosting visits from medical representatives from pharmaceutical companies on an almost daily basis, and RMPs in India overwhelmingly referring patients to private doctors and hospitals (influenced by the commission they receive in the form of cash or equipment).
They have the capacity to organise themselves into powerful political forces. In Nigeria, the PMV Association registers and monitors its members, working to promote and defend their interests (with legal action, if necessary). In Andhra Pradesh alone, there are 11 different RMP Associations, many of which have been around since the 1960s, suggesting a long history of self-organisation. This is in contrast to northern India and Bangladesh however, where the RMPs and VDs are still highly fragmented.

This is just a snapshot of the findings from the research, deliberately selected because they work to dispel some of the persistent myths in circulation regarding informal providers. Fortunately, the appetite for further research into informal providers is strong (as confirmed in the lively Q&A debate that followed the presentation), underscored by the recognition that focusing on the dynamics of each local market is critical given the complex incentive, supply and demand networks of health provision that informal providers both drive and are themselves shaped by. One things is certain, informal providers represent a growing and undeniable force within the health community, and despite the refusal of some governments and others to acknowledge/engage with them, it is in all our interests - particularly the patients - to begin working more effectively with these elusive actors.

This article was originally posted on the HANSHEP website and is reproduced here with their permission.

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